Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.
A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.
Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.
Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.
PSYCHIATRISTS IN HOSPITALS
Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.
Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.
The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.
Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.
Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.
Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.
Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.